1. E-Mail: POETEAM@cooperhealth.edu
CDI - Ambulatory
E & R Building
___
401 Haddon Ave, 3rd Floor
Camden, NJ
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How we can help you…
Optimize documentation capture by providing education to our clinicians on multiple aspects.
Examples:
Elements of a Level of Service (E&M)
HPI, Exam, MDM, Time
Preventive and other Patient
Management Services
Wellness, Advance Care Planning
Documenting Acuity (ICD-10)
Complications, Due to
HCCs (Hierarchical Condition Categories)
Type 2 DM with Hyperglycemia
Current Insulin Use
S/P LLE Amputation, below the knee
Surgical and Procedure Notes
Required Elements
Supporting Medical Necessity
Attestations
Surgical
E/M
Resident
Split/Shared
Incident-To
And More…
Clinical
Documentation
Improvement
- Ambulatory
TIP Sheet #2:
Injections
Ear Wax Removal
EKG
BMI
To Serve, to Heal, to Educate 

2. Injection Injection EKG For IM/FM Impacted Cerumen Adult BMI
Injections - Progress Note:
 The Issue: Injections are documented under Assessment/Plan but it is not clear if it is a future order or if administered during the office visit.
The Fix: Document Injections as Order only or as Order and Administered in Progress Note under Assessment/Plan if administered during the office visit.
 The Result: Clarity and less s from the POETeam
**If provider gives counseling to individuals 18 years of age or younger for immunizations, they must personally document it within the record.
The Issue for IM/FM: EKG tracing with provider signature and date reviewed as well as provider’s impression are not located within EPIC
 The Fix for IM/FM: The EKG tracing has to be scanned into EPIC and at a minimum it has to have the provider’s initials or signature along with the date they reviewed the tracing.
The Impression can be on the scanned tracing or it can be included in the Progress note or both.
 The Result: Clarity and less s from the POETeam
Injection – Administration:
Every injection has to have the following information documentation within EPIC for coding/billing as well as patient safety measures:
An Order for injection, ordered by_____
NDC (National Drug Code)#
Lot#
Exp Date
Route
Injection Site
Who Supplied - Patient, Office, BloodBank**
(**This is important for billing/coding to verify if coders should bill for the injectable at the time of billing for the administration)
 The Issue: Complete injection details are not entered in EPIC in a uniform manner.
 The Fix: All immunizations should be entered under Immunization Administration.
All other injectables should be entered under Medication Administration.
If the required fields are not available for the required information notify your manager so that we can have EPIC address.
The Result: Better patient care for quality and safety
Fewer s from the POETeam looking for the details
Impacted Cerumen
The Issue: Documentation does not include the details of the modality used to remove ear wax and/or does not specify if cerumen (ear wax) is impacted
 The Fix: Documentation needs to include:
- An order for PR REMOVE IMPACTED EAR WAX
- Method of removal (irrigation, lavage or with instruments)
- If with instruments, include the type (wax curettes, forceps or suction).
- Laterality for removal for correct diagnosis, Impacted cerumen (Bilateral, Right or Left)
Assessment/Plan - needs to include if the procedure is performed at office visit
The Result: Documentation and Billing Clarification
Adult BMI
The Issue: BMI details within the Assessment/Plan do not match the BMI details located in Visit Summary
 The Fix: Ensure the exam date and diagnosis information match the BMI prior to adding diagnosis within Assessment/Plan. If the BMI classifies the patient as Underweight, Overweight or Morbid Obesity and the condition as addressed during the encounter, include that diagnosis as well.
 The Result: Better Patient Care and Reporting